The figure of speech describing something as a “pain in the neck” was probably coined by someone who has never experienced temporomandibular joint (TMJ) pain. Jaw pain from temporomandibular joint dysfunction is unrelenting. You won’t have a break from your jaw pain symptoms because you use your jaw to eat, speak, swallow and yawn. Temporomandibular joint dysfunction can be treated with physiotherapy interventions. Read on to learn more about TMJ treatment and finally unstuck your jaw and beliefs about TMJ pain.

Anatomy of your TMJ

Your temporomandibular joint is located just in front of your ear and you will be able to feel your TMJ move by placing your index and middle finger in front of your ear and opening and closing your jaw.

Joint

Your temporomandibular joint is a specialized synovial joint where your temporal bone, part of your skull, articulates with your mandible, or jaw. It is specialized in the sense that this unique hinge joint allows many more movements than other hinge joints in your body, like your elbow or knee.

Your TMJ is tiny in comparison to your knee. The average knee has a volume of 23 ml, while your jaw has a volume of 2.1 ml. Your TMJ is similar to your knee, not only as a hinge, but it also contains an articular disc, like the meniscus in your knee. The articular disc of your TMJ isn’t connected to one of the joint surfaces though and divides your TMJ into a superior and inferior articular surface, top and bottom.

This articular disc is also unique in that it attaches directly to a muscle, the top part of your lateral pterygoid muscle. Remember that one for Scrabble! The back part of this articular disc attaches directly to the mandibular fossa to form the retrodiscal tissue. This just means that the contents of this space sit behind the disc. This space contains many blood vessels and nerves and is a major contributor to inflammatory TMJ symptoms because of that.

Ligaments

Ligaments attach bone to bone and aid static stability. Your TMJ has the following ligaments to keep is stable:

  • Temporomandibular ligament
  • Stylomandibular ligamant
  • Sphenomandibular ligament
  • Otomandibular ligaments (discomalleolar (DML) and anterior malleolar(AML)).

Muscles

The muscles of mastication, the ones you use to eat are responsible for moving your jaw. These include:

  • platysma
  • disgastric
  • stylohyoid
  • mylohyoid
  • geniohyoid
  • masseter
  • temporalis
  • lateral pterygoid
  • medial pterygoid

Nerves

The mandibular (CN V), facial (CN VII) and C 1, 2 and 3 innervate these muscle to allow jaw movement.

What does my temporomandibular joint do?

We generally take our jaw movements for granted, until you have TMJ pain. The muscles of mastication, listed above, work in pairs to allow jaw movements. Opening and closing to chew is all you may consider. Still, this unique condylar hinge also allows sideways movement, like a herbivore ruminating, and protraction and retraction, moving your jaw forward and backward.

These movements happen in real-time, without conscious planning from your side, to chew, talk, swallow and yawn. If you suffer from temporomandibular dysfunction, you will experience restriction in some or all of these movements. You cannot open your mouth wide enough to take a bite from a hamburger or brush your molars at the back. You feel pain when you eat, speak or yawn and if you experience clicking you will probably be worried about your jaw getting stuck.

What happens with temporomandibular dysfunction?

Temporomandibular disorders (TMD) can be divided into pathology within the TMJ, outside the jaw and other causes further away, causing referred pain.

  • Intra-articular temporomandibular joint dysfunction

Pathology within the TMJ can be caused by inflammation or structural derangement. Inflammation of the joint capsule or articular disc, causing synovitis or retrodiscitis, is caused by direct or indirect trauma. The inflammation leads to limited movement of your jaw, especially opening your mouth, and pain at rest. Deviation of your jaw away from the symptomatic side is indicative of inflammatory temporomandibular joint dysfunction, similar to the “list” resting position of acute neck or back disc injuries.

Intra-articular derangement, resulting in articular disc displacement with or without reduction, arthritis or hypermobility is discussed below. Characteristic of this type of temporomandibular joint dysfunction is a click or pop followed by the jaw moving more freely. Deviation is usually toward the symptomatic side.

  • Extra-articular temporomandibular joint dysfunction

Muscular imbalances, due to poor posture, unsymmetrical movement patterns and hobbies, like playing the violin, cause a difference in strength, endurance, length and tone of the muscles of mastication. This directly impacts the TMJ movement and symmetry. Bruxism (excessive grinding of teeth at night) or temporal tendinopathy, due to constant chewing of gum, leads to wear and tear of the articular disc and joint surfaces, which can later lead to intra-articular derangement dysfunction.

  • Other/referred temporomandibular joint dysfunction

Different neuralgias, headache patterns, vertigo, tinnitus and sinusitis may refer pain to your TMJ. This causes pain in your jaw, with no movement restriction, because the root cause lies at a different site.

Causes of Jaw Pain

  • Fractures of the mandible
  • Direct trauma from impact, like a fall or fist
  • Car accident with resulting whiplash or concussion
  • Bruxism
  • Excessive chewing of gum
  • Grinding or clenching teeth
  • Prolonged opening for dental procedure or surgery
  • Post intubation

Symptoms of Temporomandibular joint dysfunction

Extra-articular TMJ

  • Pain spread further beyond TMJ to eyes, cheeks and neck
  • Symptoms usually worse towards the end of the day
  • History of facial or neck injury
  • Recent dental procedure
  • A habit of grinding teeth

Inflammatory Intra-articular TMJ

  • Pain in jaw
  • Tightness of muscles surrounding jaw
  • Symptoms at rest, with no jaw movement
  • Limited opening range of movement
  • Jaw deviates away from the symptomatic side

Intra-articular derangement TMJ

  • Pain of jaw with movement
  • Limited movement of opening
  • Deviation of jaw toward the symptomatic side
  • Jaw gets stuck with movement
  • Audible pop or clicking followed by more freedom of movement
  • Anticipation and fear of jaw movements
  • Avoidance of meals that require big bites
  • Nervous to yawn, shout or sing that need mouth open position

Tests that you can do to see if you have temporomandibular dysfunction

  • Check your movement in a mirror
  • Open your mouth as wide as you can
  • Can you slide 3 of your fingers in between your top and bottom teeth?
  • If this is not possible you may have TMJ dysfunction

  • Check your jaw movement in a mirror
  • Open your jaw slowly
  • Does your chin move symmetrically down or is it sliding more to one side?
  • If your jaw opens skew you may have temporomandibular joint dysfunction

  • Check yourself in a mirror
  • Gently part your teeth
  • Move your jaw from side to side
  • Check how far you can move to either side
  • Pain and limited movement indicates TMJ dysfunction

How severe is my jaw pain?

The following classification has been developed for intra-articular pathology of the temporomandibular joint, specifically internal structural derangement.

Stage 1: Disc displacement with reduction

This stage of temporomandibular joint dysfunction is characterised by limited opening of the jaw and deviation towards the painful side. A pop or click may be heard once the disc reduces and you can open your mouth fully and symmetrically after this happens. The reduction does not need to be accompanied by a sound to confirm the diagnosis.

Stage 2: Disc displacement with reduction & intermittent locking

With this state of temporomandibular joint dysfunction, stage 1’s symptoms are experienced together with longer episodes of limited jaw opening.

Stage 3: Disc displacement without reduction

A closed lock is when the joint stops clicking, but is still limited to open, with less than 30 mm jaw opening. Deviation to the affected side is visible in opening and forward jaw movements. This is experienced with chronic jaw pain and tenderness.

Stage 4: Degenerative disc disease

As the temporomandibular joint dysfunction progresses, the tissue loses elasticity and as a result, gets thinner and can perforate. This usually allows more movement than with stage 3, but symptoms of pain get worse as the day goes on. MRI imaging will show the changes to the joint surfaces. Crepitus, sclerosis and osteophytes will be visible, similar to OA changes in larger joints.

Diagnosis of Temporomandibular Joint Dysfunction

Physiotherapy diagnosis

Our physiotherapists are experts in anatomy, we have experience in movement disorders and understand how something as far away as your shoulder may be contributing to your jaw pain. Do you want to get to the root cause of your problem? We have a structured plan to diagnose, classify the severity, and determine the hierarchy of priority that your TMJ needs. Our physiotherapists will find all the possibilities that could be causing your temporomandibular joint dysfunction. We will guide you on the road to recovery.

As physiotherapists, we understand the physiological healing stages you’ll go through, and custom-fit your treatment program accordingly. By knowing the extent of the tissue damage we can guide you through a structured program to safely return to singing, acting and enjoying a meal.

X-rays or OPG

X-rays show bone and are the image of choice to visualise joints. An Orthopantomagram (OPG) is a panoramic view of your jaw and teeth. This special view is needed to see your TMJ, the joint space, alignment and surfaces. These views are taken by a dentist during consultation.  Your physiotherapist can refer you to get an OPG view by your dentist, taken if necessary.

Diagnostic ultrasound

Condylar erosion will be visible on diagnostic ultrasound, but it is not the gold standard for diagnosing TMJ dysfunction.

MRI

With an MRI scan all the structures in your TMJ can be visualised, including the joint surfaces and articular disc. This is a costly image that only a specialist can order, in this case, a maxillofacial surgeon. If your physiotherapist suspects stage 3 or 4 intra-articular TMJ pathology, you will be referred to the right specialist.

Why is my jaw pain not going away?

You cannot expect a different outcome from a wait-and-see approach because you don’t change your intervention. Waiting and hoping wastes valuable time when quick intervention could have led to positive change.

Each time you experience TMJ pain the joint undergoes an inflammatory reaction. This changes tissue integrity and elasticity, causing more stiffness and pain.

If you get stuck in this cycle of pain, rest and returning pain, you risk long-term complications of your temporomandibular joint. This can result in frequent locked TMJ episodes, which ultimately steal away from your quality of life. Get the right help to enable you to do what you love.

What NOT to do

  • Continuous use of anti-inflammatory medication only masks your symptoms

  • Turn your jaw reduction into a party trick

  • Do not ignore jaw pain that gets worse (it could be an sign of a deeper problem)

  • Leave your TMJ dysfunction untreated, if you are uncertain of the diagnosis, rather call us and be safe

What you SHOULD do

  • Avoid activities that flare your TMJ pain, like chewing gum

  • Make a list of movement or activities that brings on your pain and rank them

  • Make an appointment to confirm your TMJ diagnosis and determine how severe the tissue damage is

  • Finish your treatment and rehabilitation programme for better long-term results

Making jaw pain worse

  • Clenching your teeth

  • Poor ergonimics when working at your computer

  • Resting your chin on your hands during class or meetings

  • Unnecessary chewing of toffees or gum

  • Biting your nails

  • Apical breathing pattern

  • Taking bites that are too big, like apples or burgers

Problems we see when patients come to us with temporomandibular joint dysfunction

Complications

Chronic temporomandibular joint dysfunction can alter how you look. This happens because of compensatory movement strategies that ultimately cause muscle imbalances that can change the shape of your face.

Anticipation of clicking your TMJ can lead to fearful behaviour around meals or other social interactions.

Waiting too long

The longer you wait, the bigger your chances of causing more joint damage. You won’t drive to Cape Town with your car if you know your wheel alignment is out, right? Why chew, yawn, laugh and speak if your jaw alignment is out?

Medication

Irresponsible use of over-the-counter medication can cause long-term damage to your digestive tract, like ulcers. Medication is a pain management tool and should be used responsibly.

Incorrect diagnoses and treatment

This article and all the information we provide are to give you a better idea of what the spectrum of the problem can be. However, making the wrong assumptions and doing more advanced exercises or stretches in the wrong healing phase can delay your recovery. There’s a lot of advice online on what to do, but they have no idea the extent of your tissue damage and severity, not to mention the subtle secondary complication you may have. Instead, know exactly what you’re dealing with before jumping into home remedies.

Physiotherapy TMJ Treatment

Our physiotherapists are experts in rehabilitation and understand biomechanics. We have studied how joint movement can influence the local tissue, but also contribute areas further away. Muscles are our friends, in that we understand how stabilisers are different from mobilisers and what each one needs. Flexibility, control, endurance and strength are the commodities we deal with daily. There are no shortcuts to healing.  It’s important to do the right exercise at the right time as your TMJ treatment progresses. We will guide you every step of the way.

Phases of rehabilitation for TMJ treatment

1st Phase of TMJ treatment: Symptom management & contributing factors (Weeks 0 – 2)

Our first aim is to get the right diagnosis and identify and prioritize any contributing factors to your unique problem. Now, we can guide you in avoiding any aggravating activities, like chewing gum, for the time being.

Physiotherapy TMJ treatment techniques will be aimed at relieving your symptoms and include electrotherapy modalities, manual joint and muscle work (yes, inside your mouth too) and exercises. If we have found contributing postural habits and muscle weakness, we can address that from the get-go.

To progress to the next stage of your TMJ treatment, you should understand your diagnosis, what to avoid and what exercises to do at home.

2nd Phase of TMJ treatment: Self TMJ treatment techniques (Weeks 3 – 4)

During this stage of your TMJ treatment, you will be guided on what to do if your TMJ gets stuck as a form of self-treatment. You can expect isometric holds,  self mobilisations and stretches, depending on your unique situation.

We expect your symptoms to be much relieved and incidents of reductions (pops & clicks) to be less.

3rd Phase of TMJ treatment: Symmetry (Weeks 5 – 6)

Now we get to the little details. It’s great if you can open and slide your TMJ more, but can you do it symmetrically? Expect mirror based exercises where the quality of movement far outweighs the quantity of repetitions.

To move on to the next phase of your TMJ treatment, we expect you to have good control and corrective strategies for symmetrical mouth opening and closing and lateral deviation.

4th Phase of TMJ treatment: Range of motion (Weeks 6 – 7)

We aim to gain as near to full mouth opening range of motion for you now that you have established symmetrical movement patterns. Your unique situation and joint surface will determine if we expect to reach the average 40 – 60 mm.

5th Phase of TMJ treatment: Endurance (Weeks 8 – 9)

Now that you understand, can self treat when necessary and feel confident to move symmetrically we aim to up your reps to make sure that you can have the long conversations, laugh out load, sing in the shower and eat what your heart desires.

Healing time for jaw pain

Healing time varies according to your TMJ diagnosis. It is important to get the right diagnosis and address all the contributing factors to give you a realistic timeline. Extra-articular temporomandibular dysfunction can be treated more aggressively to reduce overall healing time, and may take 4 – 6 weeks. It would help if you had rest and possibly a bite plate for intra-articular temporomandibular pathology, which may need 8 – 12 weeks to heal.

Other forms of medical treatment for temporomandibular joint pain

  • Your doctor (GP) can prescribe a short course of anti-inflammatory, analgesic or muscle relaxant medication for symptom relief, while we address the root cause of your temporomandibular joint dysfunction.
  • Your dentist/neurologist can do Botox injections for longer term symptom relief, if your TMJ pain is caused by overactive/imbalanced muscles.
  • If you have altered your biting due to toothache, your dentist can assess and treat any cavities contributing to your TMJ pain.
  • A bite plate can be considered if you grind your teeth at night.
  • Relaxation techniques are appropriate if your TMJ pain is more severe when you are under stress, this can include diaphragmatic breathing techniques.

Is surgery an option for my TMJ?

TMJ surgery is performed by a maxillofacial surgeon. It is only considered where:

  • structural damage is confirmed with MRI
  • you have constant symptoms impacting your quality of life and
  • you have not had success with non surgical treatment.

Surgical options include arthroscopy or open procedure. Both are normally done as out patient procedures and you should be able to go home the same day. You will be able to start rehabilitation within a few days to regain movement that will enable you to talk and eat comfortably.

It is important to follow your post-operative rehabilitation to regain symmetrical movement of your jaw.

What else could my jaw pain be?

Whiplash or other injury to your high cervical spine can cause referred pain to your jaw.

Vertigo and balance dysfunction, caused by a viral infection of the vestibulocochlear nerve (CN VIII), may also cause as jaw pain.

Cervicogenic, cluster and tension type headaches may also cause jaw pain.

  • Trigeminal neuralgia

One-sided facial pain with a sharp, shooting quality can be caused by inflammation or compression of CN V.

  • Bell’s Palsy

One-sided facial paralysis, caused by compression or inflammation of CN VII, can lead to jaw pain.

Temporomandibular joint dysfunction also known as:

  • TMJ
  • Jaw pain
  • Temporomandibular joint pain